246368 06/1 7/1 5 (9,
CITY OF CARMEL, INDIANA VENDOR: 355486
ONE CIVIC SQUARE INDIANA ALCOHOL &TOBACCO COMNPHECK AMOUNT: S*******100.00*
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 246368
INDIANAPOLIS IN 46204 CHECK DATE: 06/17/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4239039 APPLICATION 100.00 GENERAL PROGRAM SUPPL
Carmel • Clay
Parks&Recreation CHECK REQUEST ,-
Date: Monday, May 18, 2015
JlJN -9 2015
Check payable to:
Name: Indiana Alcohol&Tobacco Commission
DGiIZIC--r -w3
Address: Indiana Government Cerfter South Room 02-W. ashin ton Street
City,State,Zip Indianapolis, 1 46204
Mail check to payee X Return check to requestor
Check Amount,$ 100.00 _ Date Required:June 3rd,2015
Check needed for: Temporary BeerNVine Permit for the 3 Monon Mixer events at The Watemark
To be paid from:
PO#(if applicable) Requisition#:
Budget account-GL# 1096.60.4239039
Budget Line Description General Program Supplies
Invoice(s)MUST be attached.
Requested by(print):Traci Broman
Requested by(signature): I
A-
Approved by(signature of Division Manager):
on this date !
Form revised 7-7-08 Shared/Forms/Business Services/Check Request Form/Check Request(rev 7-7-08)
STA.rf
BEER:&WINE AUTHORITY 6TYPE 118 Send,deliver,or,mail to:
o. 3cQ
o'd = State Form 35494 District#1 52422 County Rd 17 District#4 651 S.Frontage Rd
(R6110.06),Approved by Bristol,IN 46507 Seymour,IN 47274
State,Board of Accounts Phone:574-264-9480 Phone:812-523.8314
•t
2014
INSTRUCTIONS: 1.Applicant must complete all requested information. District#2 1353 S.Governors Drive District#5 3650 S.US•Hwy 41
2.Please type or print clearly. Columbia City,IN 46783 Vincennes,IN 47591
3.Submit application and payment to the local excise Phone:260-244-4285 Phone:812-882-1292
district office. .District#3 279 W..County Rd 300 N District#6 6400 E.30th St
Craw(ordsvllle,IN 47933 Indianapolis,IN 46219
Phone:765-362-8815 Phone:317-541-4100
y &,. S P 1 GEiEl2A`L tNd�ORlIATIOta ?,� . _ _ F
n._. >.,_� 3.. s s Nom., .. ,. ��.
Name of applicant applying for permit.(organization(club,corporation,individual) E-Mallc�,rmct Cl ay TM Permit#(Issued by ATC)
par �,a 'p t ymo� ar KS. c-om
Address(numberand street city,'state,ZIP code)
235 CWAT&k ark - E. Carrel, !N 4032
Name of person making application. Fax Number Emergency contact telephone number
TrOkv+ anmm01n c 3�'1
Printed name of contact person'of.eventddiess Emergency co,ntact telephone number
�; Yp t Sanle, as .above•
A.r F 4r, TEP 2£;EVETVT INFORM-A`TION
Beginning
, Ending
Day tyAa. I Date � Day Date
Times of function: AM 2 AM
Start End_ 1 1'Q-•✓D M
Type o.r description of event
MM. :_- I.X PXcdVl� .. OVt;1cVV'I�-GL ." 1�.\l�al
Exact address of event(numberand street city,state,ZIP code)
41°t5 Pari r. W cap'IMe. ' i T 410032
w zMMy ST1EPj3FLQORT'PL,Af+I{SEE SfTEP,4, #2, _
N�1 t .
i Ieel ---
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IN-
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4 �\ 5 > V—RE MP%i4
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p 5 �
` �. , vi)r Sn�wktrcM gfraatar tnckerst
6 Revpta:rabl 3 Iuv inav,,� s <0
till dues Annymft iqs
_ 1_�., b i+,�n li r �ir� -i• ft....r .Y �`�a AC ?t► _ Se
i t`
- +•—+ary k'*'2 z^fq(^+ + p""F'8.Bi .f d t ��'ii11,?"_ ,„.. YV'G� 4t5+ .. �Cr_'`$^„;„ sR�,y *�e`'' m.a � A/r =%,y.k :q
In order to qualify forthis authority to serve beer&.,wine,-the following guidelines must be met:
1. 'There must be a.well defined premise, i.e. building, tent,.enclosure, or fenced=in or designated
area.
2. You must have. a defined floor plan.:or diagram. This is to be drawn on Page 1 Step 3 of this
application. If minor are to.be present you must have a defined separation.between the bar area
and family area,.(Must be.on floor plan).
3. There shall be, NO carry-out privileges, NO carry-in privileges and NO spirituous beverages
allowed.
4. Each applicant must designate an individual to be responsible for the event and such person shall
-sign the authority.
5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS
a valid ATC employee.permit.
6. The-event must meet applicable Board of Health requirements, particularly with regard to restroom
facilities.
7. If the event is held:in.a town park,you;must.have:approval from the town board.
8. :Legal hours.of dispensing alcoholic.beverages(Prevailing Time), Monday through;Saturday lam to
3am the following day. Sunday=7am to 3am the following day.
9. Applicant must file,with the,district office at which the event will be held at least 15 days prior to the
_.,..._event:-Failure-So..comply-will-be-grqunds-for denial,.---w-�-------
10. This authority, must be ,posted in the most conspicuous 'place at the location of the event. An
Excise Officer or Commissioner, for good cause, has the authority to revoke the.authority during
the event.
' r e R YsP a
STEPaS GOMMUt ITYCLE' C �„ ,
1. Signatuie of S hief of Pollee o-r. n Marshal where the.e nti to be1ocated. 2. slgnature of Mayoe(If event is held in Foci Wayne
Note-, ,
Plea ost your approved request in conspicuous place where the alcoholic beverages are being dispensed at the location.
If for any reason this request is denied,you inay be notified elthevin-person or by-phone. - -
1 swear or affirm Underpenalties of perjury tbat the information is true and.accurate..
Signature of permitfee!_agent. Date(month,day,yeary
(Your signature acknowledge$ahat:youhave read and will abide by the rules and guidelines.)
.rte ack �, 3 +s,y �,-a. + fi i
r � �ADtSTIr±;l1CLISE,�!IULf .. <
,,. .,.,.�.�� - �.,;� ,._��,...,. �µ
Dlstrlct number Date issued(month,day,year)
Reviewed:by E)cisePorce DistridR*eSenfawe
Approved Denied
1. ALL EVENTS ARE$50:00 PER DAY..BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE,OUT TO THE INDIANA.ALCOHOL&
TOBACCO COMMISSION.
2. SERVING'PAST MIDNIGHT,NO LATER THAN 3 A.M.,IS ONE DAY.
3. NO RAIN CHECKS ON,ANY OF'THE.ABOVE EVENTS.
STA
BEER
o4y BEER&WINE AUTHORITY/TYPE 118 Send,deliver,or mail to:
¢ State Form 35494 District#1 52422 County Rd 17 District#4 651`S.Frontage Rd.
s
..z
(R6/10-06)Approved by Bristol,IN 46507 Seymour,IN 47274
'•� "°'".t State.Board of Accounts Phone:574-264-9480 Phone:812-523-8314
•7�
2014
INSTRUCTIONS: 1.Applicant must complete all requested information. District#2 1353 S.Governors Drive District#5 3650 S.US Hwy 41
2.Please type or print clearly. Columbia City,IN 46783 Vincennes,IN 47591
3.Submit application 8nd payment to the local excise Phone:260-244-4285 Phone:812-652-1292
district office.
District#3 279 W,County Rd 300 N District#6 6400 E.30th St
Crawfordsville,IN 47933 Indianapolis,IN 46219
Phone:765-362-8815 Phone,317-541-4100
K _ S7P>i G1dINFORAA71Qf " `
£.,„t a.n.L., u✓„4t,._ 3:r�. .ck# ✓,.,n -...-«a+ .,.ku
Name of applicant applying for permit.(organization,club,corporation,individual) E-Mail- TM Permit#(issued by ATC)
Address(number and street;city;state,LP code)
1235 1-�0�t aY'k Dc E. Carmd 31 N 4b 0�>2
Name'of person making:appilcation. Fax Number Emergency contact telephone number
Traci gyDM0 ,n (?W1 5"13.52b'� ('31-1 ) 6-13.15243
Printed name'of contact person of event ddress: Emergency contact telephone number
Trac a rorn an r SaM.. aS above.
57EPFORtIR" TIO
�.. _ o �_.
Beginning Ending
Day Date A la 13 DaVINIC - Date.
Times of function: AM 2 AM
End '✓D M
Type or description of event
mvliori W X-er Gkayjln oyes 2'k e vent cat -"Ie. Wain,dry-)
Exact address of event(number and street city,state,ZIP code)
�la�a
ccnTraA Park Y-. W cox'lmd 10 AW32
E SdTE...,P, S„4
STEP LOMP, #2
M IM
ou
X �
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SMNR
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in order to qualify forthis authority to serve.beer&wine;the.following guidelines must be met:
1. There must be a .well defined premise, i.e. building, tent, enclosure; or fenced=in or designated
area.
.2. You must have a defined floor plan or diagram: This is to be drawn on Page 1, Step 3 of this
application. If minor are to.be present you must have a defined separation between the bar area
and.family.area:.(Must be on floor plan).
3. There shall be NO carry-out privileges, NO.. carry-in privileges and' NO: spirituous beverages
allowed.
4. Each applicant must designate an individual to be responsible for the event;and such person shall
sign the authority.
5. ANY and-ALL persons dispensing oraccepting paymentfor alcoholic beverages MUST POSSESS
a-valid AT.G.employee permit:_
6. The eventmust meet':applicable.Board of Health requirements, particularly with regard to restroom
facilities.
7. If the event is held in:a town park,you must have approval from the town board..
8. Legal hours of dispensing alcoholic beverages(Prevailing Time),Monday through Saturday 7am to
3am the following day.Sunday-lam to 3am the following day.
9. Applicant must file with the district office at which the event will be held at least 15 days prior to the
event. Failure to comply-will be grou.nds for denial.
10. This.authority must be posted in the most conspicuous place.at the location of the event. An
Excise Officer or Commissioner, for good cause, has the authority;to revoke'the authority during
the event.
X.
� _ s s✓ c =w a° .row �.. r�'�'r" x� ae �� '� ;� axle' ;D ,r�^ 5 �"" �. ..
% s PPoSGOMMUN..iYsL• EAR/1N �� ��eEc _ �- � = v� .
1. Signature.of Shen of Police or, , n Marshal where the evenis.to b located. 2. Signature of Mayor(if event is:held In FortWayne
Note:
Please p �tv
ur approved.request in a conspicuous placewhere.the alcoholic beverages are being dispensed authe location.
If.for any reason this.request is denied,you may be notified-either in person or by phone. -
I swear or affirm underpenalties of perjury'that.the information'is true and accu"rate.
Signature of.permittee/agent Date(month,"day,year)
(Your signature acknowledges that you have read and will eblde by the rules and guldelfnes.)
at y �ay N�,,'�.udg &a. � �A7�-1SI > EIY� � ...,$,'.u :a. '"Ci, '.^�"`E"4.�da 4;i •p �.a�,L. «�' .we. :h....^
.fid,... _ Yc r..nr n ,
Districtnumber Date issued.(month,:day,year)
Reviewed by FxcsePdeeDistridRepesertatitie
Approved Denied
1, ALL EVENTS ARE,$50 00 PER`DAY BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE.INDIANA ALCOHOL&
TOBACCO COMMISSION.
2. SERVING PAST MIDNIGHT,NO LATER THAN 3 A.M.,IS.ONE DAY.
3. NO RAIN CHECKS ON ANY OF THE ABOVE.EVENTS.
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service,where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
355486 Indiana Alcohol &Tobacco Commission Terms
IN Government Center South, Room E114
302 W. Washington Street
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
5/18/15 Application Temporary BeernlVine permit for 2 Monon mixers xx2162 $ 100.00
Total $ 100.00
I hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and I have audited same in accordance
with IC 5-11-10-1.6
120
Clerk-Treasurer
I
Voucher No. Warrant No.
355486 Indiana Alcohol &Tobacco Commission Allowed 20
IN Government Center South, Room E114!
302 W. Washington Street
Indianapolis, IN 46204 In Sum of$
$ 100.00
ON ACCOUNT OF APPROPRIATION FOR
109 -Monon Center
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1096-60 Application 4239039 $ 100.00 1 hereby certify that the attached invoice(s), or
bill(s) is(are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
I
June 11, 2015
Signature
$ 100.00 I Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund t
I
I
I